Skip to content
View in the app

A better way to browse. Learn more.

allnurses

A full-screen app on your home screen with push notifications, badges and more.

To install this app on iOS and iPadOS
  1. Tap the Share icon in Safari
  2. Scroll the menu and tap Add to Home Screen.
  3. Tap Add in the top-right corner.
To install this app on Android
  1. Tap the 3-dot menu (⋮) in the top-right corner of the browser.
  2. Tap Add to Home screen or Install app.
  3. Confirm by tapping Install.
Discussion

how can i write nursing note?give me samples?

hello

i'm anew member

i'd like to ask

how can i write nursing notes? provide me with examples?

how can i write nursing care plan?provide me with examples if possible?

with my greetings

thank u

Featured Replies

This is something best taught in a classroom, not on a website. It's hard to make it understandable without being able to talk about it and explain as you go.

I'm a student and I was having trouble with them, too. A nurse suggested to me that you do "head-to-toe" notes:

Head: How was the patient behaving? eg, pt settled/unsettled/sleeping long periods this shift.

Mouth: Intake and output: Good oral intake/tolerating selective diet/NBM for surgery. Adequate urinary output. (Include IV fluids, catheter outputs, drains, etc). NG feeds given as charted.

Chest: Obs: Obs satisfactory. Afebrile. Nil respiratory distress. Limb obs satisfactory.

Body: Cannulas, medications. IV site satisfactory: nil redness, swelling or pain at site. IV abx given as charted. Medications given as charted.Panadol given for fever of 38.9 © and discomfort with good effect. Wound intact, staples removed as per doctor's orders. Dressing intact.

Feet/legs: How does the pt move? Where did they go? Ambulant with 1/2/FASF/ whatever. CT attended. X ray attended.

Anything else? Asthma education attended by Asthma Educator. Mother concerned that pt is being "overdosed" on Ventolin. Reassured mother regarding dose. Pt sat in Tumble Tilt chair for 1 hour as ordered. SaO2 remained satisfactory, > 90%.

Those are suggestions from a paediatric medical ward. I might have missed things that would be included for surgical, mental health, cardiac, or other types of nursing. Like the PP said, it's better to do it in person, but I hope this gives you something to be going on with.:lol2:

  • Experts

http://www-isu.indstate.edu/mary/chart.htm - this is a sample of how to do a narrative charting of a head to toe assessment. it is for a patient with a recent cva.

http://www2.nursingspectrum.com/ce/self-study_modules/course.html?id=393 - "document it right: a nurse's guide to charting".

https://nursing.advanceweb.com/common/ce/content.aspx?courseid=251&creditid=1&cc=36532&sid=1095 - an article on documentation

https://allnurses.com/forums/1595750-post3.html - this is a post that has internet links to several sites that have samples of nursing care plans that you can look at

Guest
This topic is now closed to further replies.

Currently Reading 0

  • No registered users viewing this page.

Account

Navigation

Search

Search

Configure browser push notifications

Chrome (Android)
  1. Tap the lock icon next to the address bar.
  2. Tap Permissions → Notifications.
  3. Adjust your preference.
Chrome (Desktop)
  1. Click the padlock icon in the address bar.
  2. Select Site settings.
  3. Find Notifications and adjust your preference.